ALICAM Patient Info Form

Patient Information Form
Veterinarian and Hospital Information
Veterinarian Name*

First NameLast Name
Email where report will be sent*
The report will be sent to this email address
Clinic Name*
Clinic Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Clinic Phone Number*
Patient Information
Patient Name*
Client Last Name*
Patient ID
Your clinic's ID for this patient
Breed*
If other, write in breed*
Age (years/months)*
Weight (kg)*
Sex*
Capsule Serial Number*
ex: G1234.9876 or A006BV.539
Date Capsule Administered*

MonthDayYear
Date Capsule Retrieved

MonthDayYear
Duration patient was fasted (hours)*
Clinical History
Brief summary of the progression of clinical signs and reason for ALICAM*
Duration of clinical signs*
Clinical signs (check all that apply)*

VomitingRegurgitationHematemesisAnorexiaWeight lossLethargyTenesmusFlatulenceDiarrheaMelenaHematocheziaOther
Characterize the stools (check all that apply)*

Small bowel diarrheaLarge bowel diarrheaMixed bowel diarrheaOther
Does this patient have vomiting or regurgitation? (check all that apply)

NoVomitingRegurgitationHematemesisOther
Appetite*
Does this patient have weight loss?*
Body Condition Score (9-point scale)*
Current Diet*

Hill's i/dHill's w/dHill's z/dHill's z/d ultraIams Intestinal Plus (Low Residue)Purina ENRoyal Canin Low FatRoyal Canin Novel ProteinRoyal Canin HPNonprescription Novel ProteinNonprescription MaintenanceHomemadeRawOther
Diagnostic Test Results
Radiographs taken*

YesNo
Radiograph results*
Ultrasound performed *

YesNo
Ultrasound results*
Ultrasonographer*

Radiologist (ACVR or ECVDI)InternistCriticalistCardiologistGeneral PractitionerTechnicianOther
Endoscopy performed*

YesNo
Endoscopy location*

UpperLowerBoth (upper and lower)
Was endoscopy performed at the same time ALICAM was administered?*

YesNo
Were biopsies taken?*

YesNo
Biopsy results*
CBC, chemistry panel, UA abnormalities*
Fecal tests*
Other tests (ie PLI, TLI, Cobalamin, Folate)*
Imaging Findings
Current Treatment
Prokinetics *

YesNo
Prokinetic *

MetoclopramideCisaprideErythromycinOther
Corticosteroids

PrednisonePrednisoloneDexamethasoneBudesonideOther
Corticosteroid Dose/Frequency (mg/kg)
Antibiotics

MetronidazoleTylosinEnrofloxacinAmoxicillinOther
Antibiotic Dose/Frequency (mg/kg)
Gastroprotectants

OmeprazolePantoprazoleFamotidineSucralfateMisoprostolOther
Gastroprotectant Dose/Frequency (mg/kg)
Antiemetics

Maropitant (Cerenia)MetoclopramideOndansetron/DolasetronOther
Antiemetic Dose/Frequency (mg/kg)
Other Medications
Was there a response to these medications?
Additional Medical History
Other Non-GI Diseases
Additional Pertinent Information
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Veterinarian and Hospital Information

Patient Information

Clinical History

Diagnostic Test Results

Current Treatment

Additional Medical History